Starting Treatment

Jul 11, 2004

I am looking for some input regarding treatment options.

I am 44 y/o, living a healthy and active lifestyle. I have been under physician supervision since August 1999, shortly after my positive diagnosis. Since then, I have not been on any meds as my CD4's and viral load has been well within margins. As of my recent lab results from this April, my CD4 was 358 and my viral load was 153,000 (highest load to date-previous high was 48,000). These results followed an extremely difficult and stressful time in my life. My doctor and I agreed we would review additional lab results in another month and determine what course to take at that time.

At the end of last year I have moved and am under a different physician's care. In conversations with my new physician, I know he differs in opinion from my previous Doctor regarding treatment plans. My previous Doctor would have put me on Trizivir alone. My new doctor originally suggested Sustiva and Combivir. Now, in my most recent office visit, while discussing the results of this lab work, the doctor asked me to think about different regimens that would work within my lifestyle, which may differ from his original thought.

Frankly, now I'm very confused... I do plan on starting medication treatment when the doctor and I agree the time is right, and by the results of my most recent lab tests would indicate that time may be sooner than later. So my question to you is, what type of program is the best? I'm the type of person that can adhere to any regimen as necessary. Although, my lifestyle is active and my job causes me to travel frequently and internationally, I don't foresee difficulty with any regimen. The confusing part is the conflicting information I have received from my HIV physicians about medications.

I truly want to approach this in the best way possible. Your input will be valuable to me.

Thank you.

Response from Dr. Pierone

Your confusion is understandable. We go to experts for authoritative and definitive recommendations and it is quite unsettling when we get two different answers. I remember when I was in medical training as an intern and was on teaching rounds with our team and an Infectious Disease attending. Our question was, what antibiotics do we use to treat this patient with peritonitis? He proceeded to tell us about 5 different combinations that we could use for this patient, and why each should work. But this was very unsatisfying to us. We were like, enough already, just tell us the BEST one (so we can order them and go get some sleep). We were convinced that there had to be one best approach and that he was somehow holding out on us. Years later, when I was teaching interns myself, I remembered my previous desire for certainty, so I tried to offer one "best choice" for treatment of peritonitis. Of course, by then I knew full well that there were at least 4 other equally good alternatives.

It is the same deal when it comes down to initial choice of antiretroviral therapy. There is simply not one right answer. Why not? New agents keep coming out that add to the potential choices and new studies of the various combinations are being added to our knowledge base. So the target keeps moving (but this is a good thing).

Both approaches that were suggested to you are acceptable, as are many others. The original suggestion was Trizivir alone. This approach has fallen out of favor because of newer studies showing that this regimen underperforms Sustiva-based therapy in terms of the percentage of patients that get to an undetectable viral load. However, this outcome is not the only thing that matters, and many physicians still use Trizivir alone. It is a simple regimen and there are many treatment options available if it fails. Combivir and Sustiva may still be the most commonly prescribed regimen in the United States. Why? Because is has an excellent track record and is generally well tolerated. More recently, many physicians are going towards a once daily regimen with Viread, Epivir, and Sustiva because of studies showing excellent results with this regimen.

In order to approach your disease in the best way possible you should stay well informed and realize that there are many very good approaches. Also, that the original regimen you eventually begin will change in the future as we develop better distinctions regarding antiretroviral therapy. Thanks for posting and good luck!

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